Medicare SNF therapy rules: skilled services, the daily-basis rule, and the group and concurrent limit
Chapter 8 of CMS’s Medicare Benefit Policy Manual sets the level-of-care rules for a Part A skilled nursing facility (SNF) stay. A stay is covered only if four factors are all met, one of which is that skilled services are needed on a daily basis. For a stay based only on therapy, CMS says that means skilled rehabilitation on at least 5 days a week. Under the Patient Driven Payment Model (PDPM), CMS set a 25 percent limit on concurrent and group therapy combined, for each discipline. This page adds those CMS rules to the setting overview on working in nursing homes and SNFs. No payment rates or case-mix figures are copied.
Quoted from official pages checked November 10, 2026. Confirm current requirements, fees, and dates on those sites. This page is not legal advice and does not guarantee eligibility, certification, or licensure.
Sources read on November 10, 2026: the Medicare Benefit Policy Manual, Chapter 8 – Coverage of Extended Care (SNF) Services (PDF; table of contents Rev. 12283, issued 10-05-23), sections 30, 30.2.1, 30.4, 30.4.1.1, 30.4.2, 30.4.3, and 30.6; 42 CFR 409.34 and 42 CFR 483.65 on eCFR (up to date as of 11/06/2026); CMS’s Patient Driven Payment Model page (page last modified 10/06/2026); and CMS’s PDPM fact sheet Concurrent and Group Therapy Limit (a ZIP file holding two copies of the PDF: an accessible copy marked “Last Revised: 2-14-19”, which is the copy quoted on this page, and a redline copy marked “Last Revised: 8-27-19”). An address in the pattern used for other chapters (ending bp102c08.pdf) returned a not-found page that day; the address linked here is the one on CMS’s list of manual chapters.
The four factors
Section 30 states: “Care in a SNF is covered if all of the following four factors are met:” The factors are that the patient requires skilled nursing or skilled rehabilitation services ordered by a physician; “The patient requires these skilled services on a daily basis (see §30.6); and”; that as a practical matter the daily skilled services can be provided only on an inpatient basis in a SNF; and that the services are reasonable and necessary. It adds: “If any one of these four factors is not met, a stay in a SNF, even though it might include the delivery of some skilled services, is not covered.”
Who counts as skilled personnel
Section 30.2.1 says skilled services are those that “Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists; and” that “Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.”
Its note on supervision states: “‘General supervision’ requires initial direction and periodic inspection of the actual activity. However, the supervisor need not always be physically present or on the premises when the assistant is performing services.” State practice acts may set stricter supervision rules for assistants; see supervision.
What makes therapy skilled in a SNF
Section 30.4 states: “Therapy services are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist.” It also says coverage “does not turn on the presence or absence of a beneficiary’s potential for improvement from therapy services, but rather on the beneficiary’s need for skilled care.” CMS’s maintenance policy is on skilled maintenance therapy and Jimmo.
For physical therapy, section 30.4.1.1 lists conditions that must all be met. The first is: “The services must be directly and specifically related to an active written treatment plan that is based upon an initial evaluation performed by a qualified physical therapist after admission to the SNF and prior to the start of physical therapy services in the SNF that is approved by the physician after any needed consultation with the qualified physical therapist.” It adds: “In those cases where a beneficiary is discharged during the SNF stay and later readmitted, an initial evaluation must be performed upon readmission to the SNF, prior to the start of physical therapy services in the SNF”.
Chapter 8’s own sections for speech-language pathology (30.4.2) and occupational therapy (30.4.3) are short. Each says: “See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 1, ‘Inpatient Hospital Services.’” Each also points to the maintenance therapy guidance in section 30.4.1.2.E. Chapter 1’s hospital therapy sections were not read for this page.
The daily-basis rule
Section 30.6 states: “Skilled nursing services or skilled rehabilitation services (or a combination of these services) must be needed and provided on a ‘daily basis,’ i.e., on essentially a 7-days-a-week basis.” It continues: “A patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the ‘daily basis’ requirement when they need and receive those services on at least 5 days a week.” And: “(If therapy services are provided less than 5 days a week, the ‘daily’ requirement would not be met.)”
The regulation, 42 CFR 409.34(a), words it differently: “Skilled nursing services or skilled rehabilitation services must be needed and provided 7 days a week; or” “As an exception, if skilled rehabilitation services are not available 7 days a week those services must be needed and provided at least 5 days a week.” The manual’s and the regulation’s wording are left side by side.
On breaks, the regulation states: “A break of one or two days in the furnishing of rehabilitation services will not preclude coverage if discharge would not be practical for the one or two days during which, for instance, the physician has suspended the therapy sessions because the patient exhibited extreme fatigue.”
Section 30.6 also warns against spreading disciplines across the week only to fill days: “For example, if physical therapy is furnished on 3 days each week and occupational therapy is furnished on 2 other days each week, the ‘daily basis’ requirement would be satisfied only if there is a valid medical reason why both cannot be furnished on the same day.”
The facility’s duty to provide therapy
42 CFR 483.65, part of the requirements for long-term care facilities, says that when specialized rehabilitative services such as physical therapy, speech-language pathology, or occupational therapy are required in the resident’s comprehensive plan of care, the facility must “Provide the required services; or” “obtain the required services from an outside resource that is a provider of specialized rehabilitative services”. It adds: “Specialized rehabilitative services must be provided under the written order of a physician by qualified personnel.”
PDPM and the 25 percent concurrent and group limit
CMS’s PDPM page states: “In July 2018, CMS finalized a new case-mix classification model, the Patient Driven Payment Model (PDPM), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay.” No PDPM payment figures are copied here.
The CMS fact sheet explains the limit: “In order to mitigate this potential effect of PDPM, CMS imposed a limit of 25 percent on concurrent and group therapy.” It describes the earlier rule: “Under RUG-IV, no more than 25 percent of the therapy services delivered to SNF patients, for each discipline, may be provided in a group therapy setting, while there is no limit on concurrent therapy.”
On how it is measured: “Once reported on the MDS, CMS grouping software will calculate the percentage of group and concurrent therapy, combined, provided to each patient, by discipline, as a percentage of all therapies provided to that patient.” The disciplines named are “Physical Therapy, Occupational Therapy, Speech-Language Pathology”. On what happens if it is exceeded: “There will be no penalty for exceeding the 25% combined concurrent and group therapy limit.” The warning edit it quotes ends: “Consistent violation of this limit may result in your facility being flagged for additional medical review.”
The RAI Manual’s definitions of individual, concurrent, and group therapy and co-treatment are on Medicare group therapy and co-treatment.
What this page does not do
It does not copy PDPM payment rates, case-mix figures, or patient costs, and does not say whether any stay is covered. It is not legal, billing, or compliance advice. Confirm current rules with the agency or organization that publishes them, your employer, and your state board.